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A comparison of self-reported risk and protective factors and the death implicit association test in the prediction of future suicide attempts in adolescent emergency department patients

Published online by Cambridge University Press:  05 May 2021

D. A. Brent*
Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA UPMC Western Psychiatric Hospital, Pittsburgh, PA, USA
J. Grupp-Phelan
Department of Emergency Medicine, University of California, San Francisco, San Francisco, CA, USA
B. A. O'Shea
Department of Psychology, Harvard University, Cambridge, Massachusetts, USA Department of Psychology, University of Amsterdam, Netherlands
S. J. Patel
Departments of Emergency Medicine and Trauma Services at the Children's National Health System, USA
E. M. Mahabee-Gittens
Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
A. Rogers
Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, USA
S. J. Duffy
Departments of Emergency Medicine and Pediatrics at the Alpert Medical School at Brown University, USA
R. P. Shenoi
Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
L. S. Chernick
Department of Emergency Medicine, Columbia University, New York, NY, USA
T. C. Casper
Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
M. W. Webb
Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
M. K. Nock
Department of Psychology, Harvard University, Cambridge, Massachusetts, USA
C. A. King
Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
Author for correspondence: D. A. Brent, E-mail:



Concerns have been raised about the utility of self-report assessments in predicting future suicide attempts. Clinicians in pediatric emergency departments (EDs) often are required to assess suicidal risk. The Death Implicit Association Test (IAT) is an alternative to self-report assessment of suicidal risk that may have utility in ED settings.


A total of 1679 adolescents recruited from 13 pediatric emergency rooms in the Pediatric Emergency Care Applied Research Network were assessed using a self-report survey of risk and protective factors for a suicide attempt, and the IAT, and then followed up 3 months later to determine if an attempt had occurred. The accuracy of prediction was compared between self-reports and the IAT using the area under the curve (AUC) with respect to receiver operator characteristics.


A few self-report variables, namely, current and past suicide ideation, past suicidal behavior, total negative life events, and school or social connectedness, predicted an attempt at 3 months with an AUC of 0.87 [95% confidence interval (CI), 0.84–0.90] in the entire sample, and AUC = 0.91, (95% CI 0.85–0.95) for those who presented without reported suicidal ideation. The IAT did not add significantly to the predictive power of selected self-report variables. The IAT alone was modestly predictive of 3-month attempts in the overall sample ((AUC = 0.59, 95% CI 0.52–0.65) and was a better predictor in patients who were non-suicidal at baseline (AUC = 0.67, 95% CI 0.55–0.79).


In pediatric EDs, a small set of self-reported items predicted suicide attempts within 3 months more accurately than did the IAT.

Original Article
Copyright © The Author(s), 2021. Published by Cambridge University Press

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